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1.  Utility of the Life Course Perspective in Research With Mexican American Caregivers of Older Adults 
Research on caregiving of elders in Mexican American families is urgently needed. We know little about family caregivers, family transitions in relation to the caregiving role, reciprocal impact of caregivers and care recipients on one another, adaptive strategies, positive benefits of caregiving (caregiver gain), specific caregiving burdens, or supportive interventions for family caregiving. Theory derivation using the concepts and structure of life course perspective provides a way to fill the knowledge gaps concerning Mexican American caregiving families, taking into account their ethnic status as an important Hispanic subgroup and the unique cultural and contextual factors that mark their caregiving experiences.
doi:10.1177/1043659608325847
PMCID: PMC3750709  PMID: 18845694
Mexican American; life course perspective; elder caregiving
2.  Activities of Daily Living in Mexican American Caregivers: The Key to Continuing Informal Care 
Journal of family nursing  2012;18(4):439-466.
La familia drives elder care in Mexican–American (MA) families, but nursing home placement can result from day-to-day caregiving demands that increase caregiver difficulty with activities of daily living (ADLs). Using life course perspective, this article describes the initial data wave of 31 MA caregivers from a descriptive, longitudinal, mixed-methods study of 110 MA caregivers and care recipients over 15 months in their caregiving trajectories. Fifteen of 31 caregivers consistently indicated “no help needed” on the Katz ADL, whereas all but one reported “help needed” during semistructured interviews with cultural brokers. In addition to the discrepancy between results on the Katz ADL and interviews, findings include consideration of nursing home placement by moderately acculturated caregivers and minimization of their illnesses by caregivers. Additional methods of MA caregiver assessment may be needed due to the questionable accuracy of the Katz ADL; additional research should explore minimization and acculturation in MA caregivers.
doi:10.1177/1074840712450210
PMCID: PMC3739688  PMID: 22740307
family caregivers; Mexican-American; activities of daily living; minimization
3.  Effects of a 6-Month Walking Study on Blood Pressure and Cardiorespiratory Fitness in U.S. and Swedish Adults: ASUKI Step Study 
Asian Journal of Sports Medicine  2013;4(2):114-124.
Purpose
The aim of this study was to assess the effects of a six-month pedometer-based workplace intervention on changes in resting blood pressure (BP) and cardiorespiratory fitness (CRF).
Methods
A subsample of ASUKI Step participants (n= 355) were randomly selected to have changes in their BP and CRF monitored during the intervention. Pedometers were used to monitor steps taken with a goal of walking more than 10,000 steps/day. Systolic and diastolic BP were taken using an Omron automated BP cuff. Estimated VO2 max was obtained using the Åstrand-Rhyming cycle ergometer test. A multi-level growth modeling approach, and a mixed model ANOVA were used to predict changes in systolic and diastolic BP, and estimated VO2 max over time by steps, age, gender, and university site.
Results
Steps/day averaged 12,256 (SD = 3,180) during month 1 and steadily decreased to month 6. There were significant linear and quadratic trends in systolic and diastolic BP over time. Age was positively related to initial starting values for systolic and diastolic BP, and approached significance for systolic BP changes over time. Steps/day approached significance for linear changes in systolic BP. There was a significant difference between ASU and KI participants’ estimated VO2 max. There was a significant change over time in the estimated VO2 max. The number of steps taken was significantly related to changes in estimated VO2 max over time.
Conclusions
The results of the present study indicate that healthy individuals who took part in a pedometer intervention improved several cardiovascular disease risk factors.
PMCID: PMC3690731  PMID: 23802053
Workplace; Physical Activity; Pedometer Intervention; Cardiorespiratory Fitness; Blood Pressure; VO2 Max
4.  Evaluation of a Peer-led Asthma Self-Management Program and Benefits of the Program for Adolescent Peer Leaders 
Respiratory care  2012;57(12):2082-2089.
Background
Asthma is the leading chronic condition in adolescents. Nonetheless, research efforts to address adolescent asthma morbidity by applying a developmentally appropriate self-management intervention have been limited. Recently a peer-led asthma self-management program has been developed and implemented for adolescents. The purpose of the study was to assess the acceptability of a peer-led asthma program for adolescents based on participant feedback and to examine the program’s impact on asthma outcomes in peer leaders.
Methods
Adolescents with persistent asthma (N=91, 13–17 years) participated in a camp-based asthma program led by peer leaders (the intervention group) or healthcare professionals (the control group), and completed a set of program evaluation forms. Peer leaders (n=14, 16–20 years) completed study questionnaires measuring asthma knowledge, self-efficacy, asthma control and quality of life at baseline, immediately after camp, and 3-, 6- and 9-months post-camp.
Results
The peer-led group reported more positive experience with the program than the adult-led group (p=.01, Cohen’s d=.53), particularly in its usefulness in dealing with asthma. Peer leaders were rated by participants highly on knowledge (98%), attitudes (93%–96%), personal skills (91%) and perceived similarities (80%–86%). Significant improvements were found in peer leaders’ knowledge (p<.001, η2 = .87), self-efficacy (p<.001, η2=.74), asthma control (p=.01, η2=.66) and quality of life in emotional functioning (p=.002, η2=.82) and activity (p=.003, η2=.62).
Conclusion
A peer-led asthma self-management program was successfully implemented and well received by adolescent learners. Asthma outcomes in peer leaders appear to have improved as a result of the program although caution should be exercised in determining clinical meaningfulness given the modest changes in mean scores.
doi:10.4187/respcare.01488
PMCID: PMC3521097  PMID: 22710616
Asthma; Adolescents; Self-management; Peer-led program; Peer leaders
5.  Effects of a Peer-Led Asthma Self-Management Program for Adolescents 
Objective
To evaluate the effectiveness of a peer-led asthma self-management program for adolescents with asthma.
Design
Randomized controlled trial comparing a peer-led asthma program (intervention group) vs. a conventional adult-led asthma program (control group). Each program was implemented at a full-day camp.
Setting
An urban city and adjacent suburbs in upstate New York.
Participants
112 Adolescents, ages 13–17 years, with persistent asthma.
Intervention
Peer-led asthma self-management program implemented at a day camp.
Outcome Measures
The Children's Attitude toward Asthma Scale and the Pediatric Asthma-related Quality of Life Questionnaire were administered at baseline, and immediate, 3, 6 and 9 months post-intervention. Spirometry was conducted twice - prior to the intervention and 9 months post-intervention.
Results
The intervention group reported more positive attitudes at 6-months post-intervention (mean difference [Diff]= 4.11, 95%CI:0.65–7.56) and higher quality of life at 6- (Diff=11.38, 95%CI:0.96–21.7) and 9-months post-intervention (Diff=12.97, 95%CI:3.46–22.48) than the control group. The intervention was found to be more beneficial to adolescents of male gender or low family income as shown by greater improvement in positive attitudes and quality of life than their counterparts.
Conclusion
An asthma self-management program led by peer leaders is a developmentally appropriate approach that can be effective in assisting adolescents with asthma in improving their attitudes and quality of life, particularly for males and those of low socioeconomic status.
doi:10.1001/archpediatrics.2011.79
PMCID: PMC3252732  PMID: 21646583
Asthma; Adolescents; Peer-led program; knowledge; attitudes; quality of life
6.  Madres para la Salud: Design of a Theory-based Intervention for Postpartum Latinas 
Contemporary clinical trials  2011;32(3):418-427.
Background
Weight gain in young women suggests that childbearing may be an important contributor to the development of obesity in women. Depressive symptoms can interfere with resumption of normal activity levels following childbirth or with the initiation of or adherence to physical activity programs essential for losing pregnancy weight. Depression symptoms may function directly to promote weight gain through a physiologic mechanism. Obesity and its related insulin resistance may contribute to depressed mood physiologically. Although physical activity has well-established beneficial effects on weight management and depression, women tend to under participate in physical activity during childbearing years. Further, the mechanisms underpinning the interplay of overweight, obesity, physical activity, depression, and inflammatory processes are not clearly explained.
Objectives
This report describes the theoretical rationale, design considerations, and cultural relevance for “Madres para la Salud” [Mothers for Health].
Design and Methods
Madres para la Salud is a 12 month prospective, randomized controlled trial exploring the effectiveness of a culturally specific intervention using “bouts” of physical activity to effect changes in body fat, systemic and fat tissue inflammation, and postpartum depression symptoms in sedentary postpartum Latinas.
Summary
The significance and innovation of Madres para la Salud includes use of a theory-driven approach to intervention, specification and cultural relevance of a social support intervention, use of a Promotora model to incorporate cultural approaches, use of objective measures of physical activity in post partum Latinas women, and the examination of biomarkers indicative of cardiovascular risk related to physical activity behaviors in postpartum Latinas.
doi:10.1016/j.cct.2011.01.003
PMCID: PMC3070052  PMID: 21238614
Latinas; Hispanics; physical activity; intervention; social support; overweight; obesity; culture; postpartum; exercise
7.  Mexican-American Males Providing Personal Care for their Mothers 
We know little about Mexican-American (MA) family adaptation to critical events in the informal caregiving experience but, in these days of economic and social turmoil, sons must sometimes step up to provide personal care for their aging mothers. This article compares two empirically real cases of MA males who provided such care, in lieu of a female relative. The cases are selected from a federally-funded, descriptive, longitudinal, mixed methods study of 110 MA caregivers and their care recipients. In case-oriented research, investigators can generate propositions (connected sets of statements) that reflect their findings and conclusions, and can be tested against subsequent cases: Caregiving strain and burden in MA males may have more to do with physical and emotional costs than financial ones; MA males providing personal care for their mothers adopt a matter-of-fact approach as they act “against taboo”; and this approach is a new way to fulfill family obligations.
doi:10.1177/0739986311398615
PMCID: PMC3106309  PMID: 21643486
Mexican-American; males; caregivers; strain; burden
8.  Adolescents’ Perception of Asthma Symptoms and Health Service Utilization 
Introduction
Pediatric asthma is accountable for a substantial use of health care services. The purpose of this study was to systemically examine the extent to which inaccurate perception of asthma symptoms is associated with the use of health care services.
Methods
This exploratory study included 126 adolescents with asthma, aged between 13–20 years. Subjects were classified as having inaccurate symptom perception (IG), well controlled, accurate symptom perception (WCA), and poorly-controlled accurate symptom perception (PCA). These groups were compared with respect to health care utilization including emergency department (ED) visits, hospitalization and office visits and school absenteeism in the past 3 months.
Results
More adolescents in the inaccurate group had at least one hospitalization compared to adolescents in the PCA or WCA groups (23.1% vs. 11.1% vs. 2.6% respectively). A similar trend was seen for emergency department visits. Compared to WCA group, adolescents in the inaccurate group were nearly 9 times more likely to have been hospitalized, 3.4 times more likely to have visited an emergency department (ED), and 4 times more likely to have missed school days.
Discussion
Adolescents with inaccurate symptom perception are more likely to have hospitalizations, ED visits, and missed days from school as compared to those with accurate perceptions. The findings underscore the importance of screening for perceptual accuracy of asthma symptoms and call for interventions promoting accurate symptom assessment in adolescents with asthma to assure appropriate care.
doi:10.1016/j.pedhc.2009.10.003
PMCID: PMC3060703  PMID: 21320682
9.  Family Support and Asthma Outcomes in Adolescents: Barriers to Adherence as a Mediator 
Purpose
Asthma morbidity in children is associated with family psychosocial functioning. While the family plays a pivotal role in maintaining optimal asthma care the mechanism of how family support influences asthma outcomes is not well understood. The purpose of this study was to examine the role of barriers to adherence in mediating the impact of family support on asthma outcomes in adolescents.
Methods
The sample included 126 adolescents with asthma aged 13 to 20 years, living in the Northeast United States. The sample consisted of 49% Whites and 51% minorities including primarily Blacks (38%) followed by Hispanic (11%). Adolescents provided self-reported data. Structural equation modeling was performed to examine the direct and indirect relationships between family support and asthma outcomes.
Results
Family support was positively associated with asthma control and quality of life. These significant associations were mediated by barriers to adherence. Particularly, family support was found to reduce barriers concerning adolescents’ negative attitudes toward medication and healthcare providers, which in turn improved asthma control and quality of life symptoms, emotional functioning and activity domains. Adolescents’ cognitive difficulty also tended to mediate the relationship between family support and emotional functioning.
Conclusion
This study highlights the beneficial effects of family support in improving asthma outcomes in adolescents. Family support exerts the positive effect by ameliorating barriers to treatment adherence in adolescents, particularly the barriers associated with negative attitudes and cognitive challenges. The findings underscore the importance of incorporating family assessment and intervention in caring for adolescents with asthma.
doi:10.1016/j.jadohealth.2010.03.009
PMCID: PMC2963868  PMID: 20970082
Asthma; Adolescents; Family support; Asthma control; Quality of life; Barriers
11.  AN INNOVATIVE APPROACH TO RECRUITING HOMEBOUND OLDER ADULTS 
Recruiting older adults to participate in intervention research is essential for advancing the science in this field. Developing a relevant recruitment plan responsive to the unique needs of the population before beginning a project is critical to the success of a research study. This paper describes our experiences in the process of recruitment of homebound older adults to test a community-based health empowerment intervention. In our study, the trust and partnership that existed between the research team and Community Action Agency facilitated the role of the home-delivered meal drivers as a trusted and untapped resource for study recruitment. Researchers can benefit from thinking creatively and developing meaningful partnerships when conducting research with older adults.
doi:10.3928/19404921-20091029-01
PMCID: PMC2818200  PMID: 20128539
12.  Fatigue-Based Subgroups of Breast Cancer Survivors with Insomnia 
Cancer nursing  2009;32(5):404-411.
The purpose of this study was to determine if breast cancer survivors (BCS) with insomnia can be grouped according to their level of fatigue. A secondary data analysis was conducted on baseline data obtained from a randomized clinical trial that focused on a cognitive-behavioral intervention for insomnia in BCS. Participants were breast cancer survivors (n=86) with insomnia who were at least 3 months post completion of primary treatment without current evidence of disease. Three subgroups of women were identified with significant differences in fatigue, including: Exhausted (35%), Tired (41%), and Restored (24%). Results suggest a majority of women have moderate-to-severe fatigue many years post completion of treatment. Severe fatigue was associated with higher levels of other symptoms and poorer quality of life (Exhausted subgroup). Significant differences in insomnia severity, anxiety, depression, and quality of life were noted among the Exhausted, Tired and Restored subgroups. The existence of fatigue-based subgroups offers important information when providing care to BCS. By determining symptoms associated with fatigue, patient care will benefit through a shift in focus from treatment of a single symptom such as fatigue to the delivery of a tailored intervention that targets multiple symptoms.
doi:10.1097/NCC.0b013e3181a5d05e
PMCID: PMC2892713  PMID: 19661794
13.  Spirituality and Cultural Identification Among Latino and Non-Latino College Students 
The purposes of this study were to examine (a) differences in spiritual perspectives and practices of Latino and non-Latino young adults and (b) the cultural relevance of the Latino Spiritual Perspective Scale (LSPS). Studies indicate that spiritual perspectives are embedded within cultural group norms and vary significantly across ethnic groups. A cross-sectional survey design was used with a convenience sample of 223 Latino and non-Latino university students in the Southwestern United States. The Spiritual Perspective Scale (SPS), the LSPS, the Orthogonal Cultural Identification Scale, and a demographic questionnaire were used. Latinos scored significantly higher than non-Latinos in both measures of spiritual perspectives. Self-reported behavioral measures, such as frequency of personal prayer, were also higher among the Latino group. Latino cultural identification was the only significant predictor of LSPS scores. Findings from this study indicate that spirituality among Latinos has meanings specific to the cultural group context. These findings have implications for nursing research involving the conceptualization and measurement of spirituality among multiethnic groups.
Los propósitos de este estudio eran examinar: (a) diferencias en perspectivas espirituales y prácticas de jóvenes Latinos y no Latinos; y (b) la relevancia cultural de la Escala de la Perspectiva Espiritual Latina. Estudios indican que perspectivas espirituales están incrustadas entre normas culturales del grupo y varían considerablemente entre grupos étnicos. Un diseño transversal y de encuesta fue utilizado con una muestra de conveniencia de 233 estudiantes universitarios Latinos y no Latinos en el Suroeste de los Estados Unidos. La Escala de la Perspectiva Espiritual (EPE), la Escala de la Perspectiva Espiritual Latina (EPEL), la Escala Ortogonal de Identificación Cultural, y un cuestionario demográfico fueron utilizados. Los Latinos calificaron considerablemente más alto que los no Latinos en ambas medidas de perspectivas espirituales. Medidas de comportamiento auto-reportadas, como la frecuencia de oración, también estuvieron más altas en el grupo Latino. La identificación con la cultura Latina fue el único vaticinador de las calificaciones de la EPEL. Los resultados de este estudio indican que la espiritualidad entre Latinos tiene significados específicos al contexto del grupo cultural. Estas conclusiones tienen implicaciones para las investigaciones de enfermería que involucran la conceptualización y medida de la espiritualidad entre grupos multiétnicos.
doi:10.1891/1540-4153.7.2.72
PMCID: PMC2822391  PMID: 20165566
spirituality; religious practices; cultural identification; instrumentation
14.  Barriers to Asthma Self-Management in Adolescents: Relationships to Psychosocial Factors 
Pediatric pulmonology  2009;44(2):183-191.
Summary
Asthma morbidity in adolescents often results from inadequate asthma self-management. This study was to explore barriers to self-management perceived by adolescents and to examine the associations between barriers and psychosocial factors including knowledge, attitude and self-efficacy. This cross-sectional study included a total of 126 adolescents with asthma (13–21 years) representing diverse race/ethnicity groups with a wide range of socioeconomic status. Self-reported data were analyzed using descriptive statistics, factor analysis and hierarchical regression. The most frequently endorsed barrier (63%) was adolescents’ unwillingness to give up “the things the doctors say I have to give up,” followed by difficulty in remembering to take care of their asthma (53%), and then “trying to forget” that they have asthma (50%). Psychosocial factors accounted for 32% of the variance in total barrier perceptions. Factor analysis revealed barriers in four domains including negativity toward providers and the medication regimen, cognitive difficulty, peer/family influence and denial. Self-efficacy was found to be the most influential factor that showed strong negative association with all four barrier subscales independent of the levels of asthma control and sociodemographic characteristics. Poor attitudes toward asthma were also associated with barriers of cognitive difficulty and social influence after adjusting for other factors. Males consistently reported higher total barriers and barriers of negativity, social influence and denial. The gender differences were not explained by psychosocial and sociodemographic factors. This study suggests that psychosocial factors are strong predictors of barriers to self-management in adolescents. Particularly, promoting self-efficacy may be beneficial in addressing the barriers. Special attention is needed to address the higher propensity for barriers in males.
doi:10.1002/ppul.20972
PMCID: PMC2692882  PMID: 19142893
Asthma; Adolescents; Barriers; Self-management; Psychosocial factors
15.  NURSE STAFFING AND MEDICATION ERRORS: CROSS SECTIONAL OR LONGITUDINAL RELATIONSHIPS? 
Research in nursing & health  2009;32(1):18-30.
We used autoregressive latent trajectory (ALT) modeling to examine the relationship between change in nurse staffing and change in medication errors over 6 months in 284 general medical-surgical nursing units. We also investigated the impact of select hospital and nursing unit characteristics on the baseline level and rate of change in medication errors. We found essentially no support for a nurse staffing – medication error relationship either cross-sectionally or longitudinally. Few hospital or nursing unit characteristics had significant relationships to either the baseline level or rate of change in medication errors. However, ALT modeling is a promising technique that can promote a deeper understanding of the theoretically complex relationships that may underlie the nurse staffing – medication error relationship.
doi:10.1002/nur.20305
PMCID: PMC2628558  PMID: 18825733
nurse staffing; medication errors; methodology
17.  Patterns of Asthma Control Perception in Adolescents: Associations with Psychosocial Functioning 
Objective
The purpose was to identify and describe the patterns of asthma control perception in relation to actual symptom reports in adolescents and to compare the group with accurate control perception with those of inaccurate perception in relationship to sociodemographic characteristics, illness-related factors and psychosocial factors.
Methods
A sample of 126 adolescents from 13 thru 20 years of age participated in the study. Patterns of control perception were constructed based on participants’ rating of their perception of asthma control and self-reported asthma symptoms using Latent Class Analysis. ANOVAs and multinomial logistic regressions were computed for group comparisons.
Results
Participants were classified into four groups according to the patterns of control perception. Accurate groups were divided into either the well-controlled (62%) or the poorly-controlled group (7%), and inaccurate groups were manifested in accuracy either with nighttime symptoms (25%) or daytime symptoms (6%). Minority participants (p<.001) or those with low socioeconomic status (p<.001) were more likely to be represented in the inaccurate group than their counterparts. The well-controlled accurate group consistently reported higher asthma-related knowledge (p=.02), more positive attitude toward asthma (p<.001), fewer barriers to self-management (p=.04) and higher quality of life (p<.001) than the inaccurate group.
Conclusion
This study demonstrated that accuracy of asthma control perception can be classified into four criteria based on patterns of various asthma symptoms. Adolescents’ tendency toward underperception was evident. The inaccurate groups are at greater risk for psychosocial impairments. This study underscores the importance of an intervention that improves the accuracy of asthma control perception in adolescents while promoting psychosocial wellbeing among adolescents with inaccurate perception.
doi:10.1080/02770900802126974
PMCID: PMC2565509  PMID: 18773334
Control perception; Patterns; Adolescents; Psychosocial factors

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